Neuroscience Institute Headache Center Intake Form. Please list ALL medications you are currently taking, including over-the-counter
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1 Neuroscience Institute Headache Center Intake Form Please list ALL medications you are currently taking, including over-the-counter medications and supplements: Medication Allergies: Past Medical History:
2 Past Surgical History: Family History: Do you currently or have you ever smoked? If yes, how many pack per day? If yes, how long have you been smoking? If former smoker, how long ago did you quit? Do you consume alcohol? If yes, how many alcoholic beverages do you consume per day/per week? Do you use any drugs? If yes, which?
3 If yes, how many times per week? Age of first headache: When was your last headache? How many times a week do you experience any kind of headache? How many times per month do experience headaches? Are you ever headache free? Have you ever required emergency room management of your headache? If yes, when was your last emergency room visit? Are there any triggers to your headache? Any warning signs prior to headache onset? Any family history of headaches of any kind? In the last 3 months, how many days of work were missed due to headache? How many caffeinated beverages do you consume daily? Do you snore? On a scale of 1-10, how stressful is your current life situation? Is there any history of physical, emotional, verbal, or sexual abuse currently or in the past?
4 MIDAS (MIGRAINE DISABILITY ASSESSMENT) 1. On how many days in the last 3 months did you miss work or school because of your headaches? (If you do not attend work or school enter ZERO) 2. How many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches? (Do not include days you counted in question 1 where you missed work or school. If you do not attend school or work enter ZERO) 3. On how many days in the last 3 months did you not do household work because of your headaches? 4. How many days in the last 3 months was your productivity in household work reduced by half or more because of your headaches? (Do not include days you counted in question 1 where you missed work or school. If you do not attend school or work enter ZERO) 5. On how many days in the last 3 months did you miss family, social, or leisure activities because of your headaches? Total Score from questions 1-5: A. On how many days in the last 3 months did you have a headache?
5 (If headache lasted more than 1 day, count each day) B. On a scale of 0-10, on average, how painful were these headaches? (0=no pain at all, and 10=worst pain ever) PH-Q9 Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several Days More than half of the days Nearly Every day 1. Little interest or pleasure in doing things Feeling down, depressed or hopeless Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself-or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking slowly that other people could have noticed? Or the opposite- being so fidgety and restless that you have been moving around more than usual Thoughts that you would better off dead or hurting yourself in some way Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
6 Not difficult at all Somewhat difficult Very difficult Extremely difficult EPWORTH SLEEPINESS SCALE 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing SITUATION CHANCE OF DOZING Sitting and reading Watching TV Sitting inactive in a public place (e.g a theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit
7 Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic TOTAL SCORE: Please Circle medications that you have previously tried: TRIPTANS Almotriptan (Axert) Frovatriptan (Frova) Naratriptan (Amerge) Rizatriptan (Maxalt) Sumatriptan -oral, inj, nasal (Imitrex)
8 Zolmitriptan -oral, nasal (Zomig) Eletriptan (Relpax) NSAIDS Aspirin Diclofenac (Voltaren, Cambia) Etodolac (Lodine) Ibuprofen (Motrin) Ketorolac (Toradol) Indomethacin (Indocin) Ketoprofem (Orudis) Naproxen sodium (Naprosyn) COX2 Celexcoxib (eg Celebrex) Analgesics and Combination Medications Acetaminpophen/caffeine/butalbital (Fioricet) Aspirin/caffeine/butalbital (Fiorinal) Isometheptene/acetaminophen/ dichloralphenazone (Midrin) Acetaminophen/aspirin/caffeine (Excedrin Migraine) Acetaminophen (Tylenol) Decongestants (Sudafed) NARCOTIC/ OPIOIDS Butorphanol (Stadol) Fentanyl (Duragesic) Codeine Meperidine (Demerol) Long acting oxycodone (Oxycontin)
9 Oxycodone (Percocet) Tramadol (Ultram) Buprenorphine (Butrans) Morphine Hydromorphone (Dilaudid) Hydrocodone (Vicodin) Methadone ERGOTS Bromocriptine (eg Parlodel) Cafergot Dihydroergotamine IV, IM, Inhaled (DHE) Methylergonovine (eg Methergine) Anti-Histamines Diphenhydramine (Benadryl) Cyproheptadine (eg Periactin) Hydroxyzine (Vistaril, Atarax) MUSCLE RELAXANTS Baclofen (Lioresal) Carisoprodol (Soma) Cyclobenzaprine (Flexeril) Methocarbamol (Robaxin) Orphenadrine (Norflex) Tizanidine (Zanaflex) BENZODIAZEPINES/ TRANQUILIZERS Alprazolam (Xanax) Buspirone (Buspar) Clonazepam (Klonopin) Diazepam (Valium) Lorazepam (eg Ativan) Zolpidem (Ambien)
10 STEROIDS Dexamethasone (Decadron, Medrol) Methylprednisolone (Solu-Medrol) Prednisone (Deltasone) Meclizine (Antivert) ANTINAUSEA Metolopramide (Reglan) Prochlorperazine (Compazine) Promethazine (Phenergan) Ondansetron (Zofran) ANTICONVULSANTS Carbamazepine (Tegretol) Gabapentin (Neurontin) Lamotrigine (Lamictal) Levetiracetam (Keppra) Oxcarbazepine (Trileptal) Phenobarbital Phenytoin (Dilantin) Pregabalin (Lyrica) Topiramate (Topamax) Topamax XR (Trokendi) Valproic Acid (Depakote) Zonisamide (Zonegran)
11 Amitriptyline (Elavil) ANTIDEPRESSANTS Bupropion (Wellbutrin) Duloxetine (Cymbalta) Desipramine (Norpramin) Doxepin (Zonalon) Imipramine (Trofanil) Mirtazapine (Remeron) Nortriptyline (Pamelor) Trazodone Venlafaxine (Effexor) BETA BLOCKERS Atenolol (Tenormin) Metoprolol (Lopressor) Nadolol (Corgard) Propranolol (Inderal) CALCIUM CHANNEL BLOCKERS Amlodipine (Norvasc) Diltiazem (Cardizem) Nifedipine (Procardia) Verapamil (Calan) Candesartan (Atacand) Enalapril (Vasotec) ACE INHIBITORS Captopril (Capoten) Lisinopril (Zestril) DIURETIC Acetazolamide (Diamox) Furosemide (Lasix)
12 MAO INHIBITORS Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromine (eg Parnate) ALPHA-ADRENERGIC BLOCKERS Clonidine (Catapres) Doxazosin (Caradura) ANTI-PSYCHOTICS Haloperidol (Haldol) Quetiapine (Seroquel) Risperidone (Risperdal) STIMULANTS/MOOD STABILIZERS Dextroamphetamine (Dexedrine) Lithium (Lithobid) Methylphenidate (Ritalin) HORMONES Estrogen/progesterone (many OCPs) Estrogen (Premarin) Medroxyprogesterone (Provera)
13 Occipital Nerve Blocks INJECTABLES OnabotulinumtoxinA (Botox) Sphenopalatine Ganglion Block Trigeminal Nerve Blocks (supraorbital, supratrochlear, auriculotemporal, infraorbital) SUPPLEMENTS Butterbur (Petadolex) Co Q 10 Feverfew Magnesium Melatonin Migrelief Vitamin B2 NEUROMODULATION Cefaly GammaCore Transcranial Magnetic Stimulation (TMS) NON-MEDICATION TREATMENTS Biofeedback Cognitive Behavioral Therapy Meditation Craniosacral Therapy Acupuncture Physical Therapy
14
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